Provider Demographics
NPI:1285754374
Name:MARUCA, EDWARD ANTHONY JR (DENTIST)
Entity type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:ANTHONY
Last Name:MARUCA
Suffix:JR
Gender:M
Credentials:DENTIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1041 3 AVENUE
Mailing Address - Street 2:
Mailing Address - City:DUNCANSVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:16635
Mailing Address - Country:US
Mailing Address - Phone:814-695-0920
Mailing Address - Fax:814-695-0926
Practice Address - Street 1:1041 3 AVENUE
Practice Address - Street 2:
Practice Address - City:DUNCANSVILLE
Practice Address - State:PA
Practice Address - Zip Code:16635
Practice Address - Country:US
Practice Address - Phone:814-695-0920
Practice Address - Fax:814-695-0926
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-30
Last Update Date:2008-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS015925L122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0005115110001Medicaid